1.1 Introduction
This handbook is shaped by a basic set of questions and ideas about mental health policy. At the outset, two questions are paramount. First, what do we mean by mental health policy? And, second, how does mental health policy change over time in response to activities within the mental healthcare system and within the context of broader social and political forces?
A dictionary definition of policy refers to high-level plans or formulations to set forth and implement a particular set of goals or objectives. Policy includes laws and court decisions, regulations and guidelines, particularly those developed within the public sector, but also in some instances within the private sector. In the case of mental health policy the World Health Organization refers to āthe vision for the future mental health of the population, specifying the framework that will be put in place to manage and prevent priority mental and neurological disorders.ā Such plans are designed to affect the life outcomes for individuals who experience a mental disorder. According to a conceptual approach to social policy developed by David Gil [1], these policies focus on the division of labor within a field of interest, the distribution of rights to individuals, and the allocation of scarce resources.
Mental health policies seek to coordinate resources and essential services for those in need or to create incentives to improve outcomes or to promote efficiencies in the system of care and treatment. To do so mental health policy requires a plan that lays out a detailed scheme to implement the policy vision and objectives, identifies targets to be achieved, and specifies the roles of various stakeholders in the implementation process.
The title of this chapter refers to two of our core ideas: fundamental reform and incremental change. By fundamental or radical reform we refer to a far-reaching set of principles designed to change the basis for addressing policy in mental health. These principles usually have a strong driving force and affect a wide array of policy areas, such as the division of labor, rights, and resources. Fundamental reform is said to be transformational and sweeping. Incremental change stands in contrast to fundamental or radical change in the narrowness of its scope and likely effects. Incremental changes are taken one step at a time and usually fall within the scope of a larger vision of policy and practice.
This handbook does not subscribe to a general theory of history or policy change, but our experience tells us that there are repeating patterns of change. Once formulated, policies and plans change through implementation successes and failures, evolving understanding of mental illness and its proper treatment, as well as changes in the broader political, economic, and social environment. A review of the history of mental health policy and careful observation of the evolution of policies on mental health services over the past four decades both suggest that there is meaning in the patterns of reform. It is instructive to examine these patterns to understand how policy changes and how we might do a better job of making policy in the future. That is the focus of this initial handbook chapter.
In the Prologue to their book on federal mental health policy, Grob and Goldman wrote: āHistory, of course, never quite repeats itself, nor are its ālessonsā self-evident. Nevertheless, we live with the results of earlier policies. To be sure, much has changed, yet we continue to hear the same dissatisfaction and lamentsā [2, p. 12]. This chapter examines some familiar patterns that are described in more detail in the other chapters in the handbook.
1.2 Cycles of Reform
In a series of publications [3ā5] based on the seminal research of Gerald Grob [6, 7], beginning in 1980, Howard Goldman and Joseph Morrissey described several cycles of reform in mental health services policy. The cycles, beginning in the first half of the nineteenth century, followed a recurrent pattern with a focus on policies designed to treat mental illness early in its course in an effort to prevent acute conditions from becoming chronic and disabling. Each turn of the cycle was motivated by a grand theory of fundamental reform promising to prevent chronic mental illness through early treatments provided in newly developed treatment settings. Each time the proposed theory foundered on the limitations of the treatment technology to make good on the promises of early intervention. As a result, in each reform cycle, mental health policies ended up focusing on administrative details and incremental changes, rather than on fundamental reform and comprehensive system transformation.
Three of the reform cycles occurred roughly over the 100-year period spanning pre-Civil War reform movements in the mid-nineteenth century to the Progressive era at the turn of the twentieth century through to the post-World War II years: They were the moral treatment era of the asylums, the mental hygiene movement of psychopathic hospitals and clinics, and the community mental health center reforms.
Early nineteenth-century reformers proposed that moral treatment offered early in the course of a mental illness, delivered in newly developed asylums, would eliminate the need to care for disabled individuals at home or in undifferentiated institutions, such as jails, workhouses, and poorhouses. Initial enthusiasm led to a period of asylum building throughout the nineteenth century in the United States, but by the time of Reconstruction in the 1870s, States had already begun admitting the defeat of the radical reform strategy when they began building ever-larger institutions, including some intended only for long-stay, chronic patients, who never left those hospitals alive [3ā5].
In the late nineteenth and early twentieth century, reformers who believed in the rise of scientific medicine and the ideals of the Progressive movement put forward a new fundamental reform. The new mental hygiene approach to treating mental illness again suggested that early treatment of individuals with mental disorders, using new scientific advances in medicine delivered in clinical settings close to academic medical centers, would improve treatment outcomes and prevent chronic disability. Mental hygiene interventions in psychopathic hospitals and clinics would reverse the trends toward ever-growing institutions warehousing individuals with a whole range of mental disorders. The second cycle of reform had about the same unsatisfactory consequences as the first with respect to achieving the goals of preventing chronic mental illness. There was more treatment in outpatient settings as a result of the mental hygiene movement, and new ideas entered treatment and services through incremental administrative changes, but there was no fundamental reform to be sustained [3ā5].
The third cycle was based on the experiences of World War II, in which early treatment and emotional support of combat soldiers and flyers close to the frontlines allowed them to return quickly to their fighting units. On the home front, following a tragic fire at the Cocoanut Grove nightclub in Boston in November of 1942, psychiatrists learned to support first responders and members of the affected community of survivors. They developed theories of community mental health treatment and preventive psychiatry to be practiced in community mental health centers (CMHCs). In addition, during this post-war period, journalists wrote several shocking exposes of widespread neglect of patients in mental hospitals. Together these forces gave rise to a community mental health movement, which was crowned with the passage of Community Mental Health Center Acts in the mid-1960s. For the most part, this fundamental reform, while very successful in expanding treatment opportunities in communities, failed to realize its promises of reducing chronic mental illness, as had been the case with the earlier reform movements [3ā5].
In the 1970s an entirely novel cycle of reform was introduced as the initial phase of the community mental health movement became mired in the problems associated with deinstitutionalization, the dramatic reductions of resident populations and beds in state-operated psychiatric hospitals [2, 5].
By the mid-1970s critics questioned the policies and practices of the community mental health reforms. Chronic mental illness emerged as a challenge, as States pursued an aggressive policy of reducing the use of public mental hospitals, discharging patients to the community or to other residential settings, such as nursing homes and board-and-care homes. CMHCs were focusing on a broad set of mental health problems and were not focused primarily on individuals with disabling conditions. And the treatments offered in the centers had neither prevented mental disorders nor rendered them nondisabling [2, 5].
The National Institute of Mental Health (NIMH), which ran the federal CMHC program, responded to the criticism by developing a program of community support services and systems and started a fourth cycle of reform. The community support reform was predicated on a fundamental shift in the delivery of mental health services. It changed the prior emphasis on early treatment to prevent chronicity to an approach to support individuals already disabled by mental disorders. In addition to treatment services, the reform proposed a broad set of social supports and community activities designed to improve the quality of life of individuals who had a chronic mental illness. The fourth cycle of reform was a dramatic departure in this regard from the three earlier reform cycles. It fundamentally changed the emphasis of public mental health systems ushering in services such as supported housing and supported employment [2, 5].
Other changes to the community support movement have influenced policy, as well, particularly as a result of the find...